Health

Accelerating fertility decline and investing in health to harness the demographic dividend in Tanzania Key messages  The high child dependency burden in Tanzania is a key bottleneck undermining socioeconomic development and the attainment of Vision 2025.  The rapid decline in fertility from the current 5.2 births per woman to converge towards replacement level will lower the dependency burden and open the window of opportunity for harnessing the demographic dividend.  Increasing the demand, supply and informed and voluntary use of contraception, maintaining girls in school and legislating against early marriages will accelerate fertility decline in the country.  Improvement in health should also include a focus on strengthening the capacity of the health system to prevent, diagnose and treat communicable and non-communicable diseases, address child malnutrition and maternal morbidity/mortality and ensure sustainable health care financing

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Accelerating fertility decline and investing in health to harness the demographic dividend in Tanzania

Acknowledgment This Policy Brief is derived from the report of the Tanzania Demographic Dividend study, which was supported by Pathfinder International-Tanzania, with technical contribution from the Department of Economics, University of Dar es Salaam, and the African Institute for Development Policy (AFIDEP).

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Context The current high level of fertility in Tanzania in the midst of steadily declining child mortality has resulted in a huge child dependency burden. The country’s total fertility rate declined by one child, from 6.3 children in 1991/92 to 5.2 children per woman in 2015/16. The decline in the under-five mortality rate has been more impressive, from 137 deaths per 1000 live births in 1996 to 67 deaths per 1000 live births in 2015/16.1 The combined effect of these two forces is a trebling of the population from 12.3 million in 1967 to 44.9 million by 2012.2 The country’s population is projected to reach 129 and 189 million by 2050 and 2070, respectively, even if fertility declines to 4.3 by 2030, 3.3 by 2050, and 2.7 by 2070.3 With 44% of the total population below age 15, Tanzania has a high child dependency burden which is a major bottleneck to the economic transformation envisaged in its long-term development strategy, Vision 2025. A rapid decline in fertility from the current level would change the age structure to one with significantly more working-age adults relative to dependent children and open a window of opportunity for accelerated economic growth known as the Demographic Dividend.4 The decline in child mortality is a critical precondition for fertility decline because parents are assured though they have fewer children, these children have a decent chance to survive to adulthood. Beyond child mortality, Tanzania also faces other critical health conditions including child malnutrition, maternal morbidity and mortality, non-communicable diseases, malaria and HIV/AIDS. It is, for instance, estimated that 34% of all children under-five years in Tanzania are stunted. Malaria accounts for over 30% of the national disease burden while non-communicable diseases are estimated to account for 31% of all deaths.5 Investment in child nutrition will improve child survival and facilitate further fertility decline as well as produce a healthy future workforce. Improvements in the disease burden of the adult population will also create a productive labour force that will help propel the country to harness the demographic dividend.

This brief highlights key policy and programme options that can help accelerate the fertility decline in Tanzania to open the window of opportunity for the demographic dividend and create a healthy workforce that will propel the country to harness its dividend. The brief is derived from a study carried out to assess the potential demographic dividend that Tanzania can earn under various policy scenarios.6

Investing in family planning to accelerate fertility decline While contraceptive use in Tanzania has improved over the years (Figure 1), the prevailing CPR of 32% is still low and falls far short of the country’s One Plan II to increase the CPR to 45% by 2020. Contraceptive use rates in Tanzania are particularly low among poorer, rural and married women with no formal education, with a CPR of 20%, 31% and 24% respectively compared to 35%, 35% and 36% among the wealthiest, urban and women with completed primary education, respectively. In addition, in 2015, 22% of married women had an unmet need for family planning, meaning they wanted to delay or avoid pregnancy yet they were not using an effective family planning method. Tanzania, therefore, needs to reposition its family planning programme to increase contraceptive use and reduce the high level of unmet need for family planning. In particular, the family planning programme needs to prioritize contraceptive demand, access and use among poor, rural and uneducated women. Also, there is need to identify the drivers of the slight increase in fertility rates and unmet need for family planning among urban women in 2015. For this to happen, the country will need to decisively and enthusiastically provide political leadership, commit financial and technical resources and mobilize all key stakeholders to address the supply and demand barriers of access and use of family planning services. The renewed FP2020 commitments made in July 20177 should form a reference point for the FP programme on priority target population and geographical regions to increase contraceptive uptake.

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Ministry of Health (MOH) National Bureau of Statistics (NBS) [Tanzania] and ICF Macro. 2016. Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015-16. Dar es Salaam, Tanzania, and Rockville, Maryland, USA: MoHCDGEC, MoH, NBS, OCGS, and ICF. National Bureau of Statistics, Dare salaam and Office of Chief Government Statistician, Zanzibar, 2013. 2012 Population and Housing Census (PHC): Population Distribution by Age and Sex United Nations, Department of Economic and Social Affairs, Population Division (2017). World Population Prospects: The 2017 Revision, custom data acquired via website.

Bloom, D., David Canning, & Sevilla, J. (2003). The Demographic Dividend: A New Perspective on the Economic Consequences of Population Change, by, RAND MR-1274-WFHF/DLPF/RF, 2002, 100 pp., ISBN: 0-8330-2926-6. Santa Monica, CA, USA. WHO, 2014. Non-communicable Diseases (NCD) Tanzania Country Profiles , 2014 Pathfinder-Tanzania, UDSM, AFIDEP, 2017. Prospects and challenges of harnessing demographic dividend in Tanzania. Dar es Salaam, Tanzania Government of Tanzania, 2017. FP2020 Commitments 2017 update http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/ uploads/2017/08/Govt.-of-Tanzania-FP2020-Commitment-2017-Update-SO-CL.pdf

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Figure 1: Trends in fertility, contraception and unmet need for FP in Tanzania (1991-2015)

Source: Tanzania Demographic and Health Surveys (TDHS), 2015

Legislating against child marriages and maintaining girls in school and to facilitate fertility decline Tanzania’s high fertility regime is characterized by early marriages, early pregnancies and high school dropout rates, especially among girls. It is estimated that half of Tanzanians women aged 25-49 years marry by age 19. Child marriages are still very common among girls. Thirty-six percent of women age 15-49 were married before age 18 compared to 5% among men of the same age. Early marriages expose girls to early childbearing that increases the likelihood they will be expulsed or drop out from school and have more children in their lifetime than if they delayed childbearing. The percentage of women aged 15-19 who have had a birth or are pregnant increased from 23% in 2010 to 27% in 2015/16 (Figure 2). Tanzania’s Marriage Act of 1971 which set the marriage age for girls at age 15 with parental consent is yet to be amended in spite of a recent high court ruling declaring the law unconstitutional. Thus, there is need to urgently amend this law and to adequately enforce the amended provision to eradicate child marriages. There is also the need for interventions to change cultural norms that favour child marriage. These measures will help to delay childbearing and consequently reduce fertility.

Women’s level of education and the years of schooling are also linked to teenage childbearing in Tanzania. It is estimated that 52% of teenage girls with no education in the country have begun childbearing compared to 34% and 10% of their peers with primary and secondary education, respectively. Therefore, ensuring that girls are enrolled and stay longer in school delays childbearing and reduces child marriage. More educated women also tend to use health services for themselves and their children and families, including family planning, more than their uneducated counterparts. Yet, Tanzania’s gross enrolment rate for females in upper secondary school in 2014 was only 8%. The average years of schooling for females in 2015 was also estimated at just 5.4 years. It is therefore important for the country to increase access to education for girls, especially at secondary and higher levels in order to promote fertility decline.

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Figure 2: Median age at first marriage and proportion of teenage child bearing in Tanzania (1991-2015)

Source: Tanzania Demographic and Health Surveys (TDHS), 2015

Key policy recommendations to accelerate fertility decline Tanzania should endeavour to explore and implement the following intervention options to accelerate fertility decline and open the window of opportunity to harness the demographic dividend: 1. Declare FP a key intervention for national development and mobilize all sectors to contribute to FP programmes and empower leaders at all levels of government and political systems to champion FP. 2. Ensure the FP programme is sustainable by increasing the national budget allocated for FP commodities as per the renewed 2017 FP2020 commitments and educational campaigns to generate demand for smaller families and address pervasive concerns about effects and use of contraception.

3. Strengthen health systems to improve access to quality family planning and other reproductive health services, paying particular attention to expanding method choice, provision of long-acting methods, and coverage of under-served groups like youth, underserved geographical regions, the poor, and men.

4. Strengthen community ownership and community-based distribution of FP by providing training and employment, and ensuring that community health workers are equipped with necessary supplies.

5. Legislate against child marriages and mobilize communities to keep girls in school, with particular emphasis on the attainment of universal secondary education.

6. Address the cultural, social and economic barriers that increase school drop-out rates and sensitize communities to value the education of girls with its benefits at household, community and national levels.

7. Strengthen public-private partnership in promotion and delivery of FP services

Improving health outcomes and creating a healthy work force in Tanzania A healthy workforce is critical for increased economic productivity and growth. There is evidence that a one-year increase in life expectancy could increase GDP by up to 4%.8 Over the past 15 years, Tanzania has seen some improvement in the health of its population. These improvements have resulted in an increase in life expectancy from 58.8 years in 2005 to 62.8 years in 2015. Despite the progress, Tanzania is still grappling with a number of health challenges including child malnutrition, low coverage of immunization, maternal mortality, malaria, HIV/AIDS and non-communicable diseases.

8 Bloom, D.E., Canning, D., and Sevilla, J. (2004). The Effect of Health on Economic Growth: A Production Function Approach. World Development Vol.32, No.1, pp.1 – 13.

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Key health challenges Maternal mortality is a key health challenge facing Tanzania. The estimated maternal mortality ratio of 556 deaths per 100, 000 live births in 2015 is higher than the ratios reported in 2010 (454) and 2012 (432). The loss of women during pregnancy and delivery impacts negatively on the economy and creates a serious pitfall in development. There is evidence that women’s incomes go towards food, education, medicine and other family needs, a direct investment in the family’s well-being.

A large proportion of children in Tanzania do not receive adequate nutrition (Figure 3). Child malnutrition is a manifestation of poverty, food insecurity and poor nutrition of reproductive-age women. Malnutrition affects cognitive development, physical work capacity and exposes people to various chronic diseases during adulthood. Malnutrition is also an underlying factor in almost 50% of child deaths. Child mortality had declined significantly, mainly linked to the improvements in health services, including extensive coverage of under-five immunization, vitamin-A supplements, use of insecticide-treated bed nets and advanced malaria drugs. However, neonatal mortality is not declining as fast and accounted for close to two-fifths of all under-five mortality.

Another major public health concern is malaria, the leading cause of morbidity and mortality, particularly among children under-five and pregnant women. Malaria prevalence in the country actually increased from 9% in 2011-2012 to 14% in 2015-2016.9 Over 93% of the population is at risk of malaria because they live in areas where transmissions occur.

Furthermore, Tanzania is witnessing an increasing prevalence of non-communicable diseases (NCDs) which contribute significantly to the disease burden, especially among the adult population. According to the WHO (2014), 26% of adult deaths in Tanzania are caused by NCDs. The main NCDs in Tanzania include cardiovascular diseases, cancers and diabetes.10 Tanzania’s health sector is facing a big shortage of Health workers at all levels, which negatively affects the delivery of healthcare services to the Tanzanian people. The country is below the WHO health worker staffing ratios, with shortages of 87.5% and 67% in private and public hospitals, respectively.11 Figure 3: Percentage of under-five children classified as malnourished in Tanzania (1992-2016)

Source: Tanzania Demographic and Health Surveys (TDHS), 2015

9 Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF International 2013. Tanzania HIV/AIDS and Malaria Indicator Survey 2011-12. Dar es Salaam, Tanzania: TACAIDS, ZAC, NBS, OCGS, and ICF International.

10 WHO (2014). Non-Communicable Diseases Country Profile. Geneva.

11 Nathanael Sirili, Angwara Kiwara, Obadia Nyongole, Gasto Frumence, Avemaria Semakafu, Anna-Karin Hurtig, 2014. Addressing the human resource for health crisis in Tanzania: the lost in transition syndrome. Tanzania Journal of Health Research. 16(2)

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Key policy recommendations to improve health outcomes and create a healthy workforce To create a healthy workforce that will propel Tanzania to harness the demographic dividend, the country needs to implement the following interventions aimed at improving health outcomes: 1. Increase and sustain funding for the health sector to ensure universal health care, with more focus on areas where little progress has been made such as reducing the maternal mortality.

2. Strengthen the implementation of the country’s nutritional programme to address the high levels of malnutrition.

3. Expand provision of Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) services particularly in rural areas and poor urban settings in order to sustain recent gains, with emphasis on health promotion campaigns and community-based delivery of services.

4. Increase investment in health infrastructure, health workforce development including deployment and retention of health personnel in hard to reach areas.

5. Address the delivery of health services that address a growing burden of chronic and degenerative diseases.

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